Continuing Education through Cultural Exchange

Not only does diabetes run rampant among Native Americans, it has recently reached epidemic levels in third-world countries as well. In May 2008, a team from Ada, Oklahoma, comprised of East Central University (ECU) nursing program graduates and Chickasaw Nation employees, traveled to Belize in Central America to share their knowledge of diabetes prevention with the Punta Gorda community. This five-day trip is associated with an overall tribal project initiated to provide Chickasaw youth an opportunity for cultural exchange and participation in community services in a third-world country. Dr. Judy Goforth Parker, who at that time was a Chickasaw Nation Legislator and ECU community health professor, along with Jay Keel, administrator of Chickasaw Nation Youth and Family Services, led this team, including recent nursing graduates Tara Fall, Casey Greer, Macy Mitchell and Monica Winford along with other team members Stacie Carroll, Deanna Kendall and Chris Snowden.

The team was met by Global Outreach International missionary Bob Farley upon arriving in Punta Gorda, and they were invited to attend services the next morning at the Laguna Community Church. They were relieved to hear that the service was presented bilingually in both Kekchi Maya and English. (There are four languages prevalent in Punta Gorda. Most children spoke English as well as their native language.)

The team visited schools and provided teachers and students of all ages with valuable information concerning diabetes prevention. A skit was performed to demonstrate how the body’s insulin plays a vital role in regulating blood sugar, and pictures of food were dispersed to encourage students to choose healthier snacks with less carbohydrates and sugar. The children agreed to ask their parents to “get moving” and play catch or take a walk with them. Storybooks taught them that physical activity is important their entire life. Hand hygiene was emphasized with explanations of the various ways worms can invade the body. The children eagerly joined in singing, “If you’re happy and you know it, wash your hands.” This helps them remember to wash their hands for 30 seconds before meals and after bathroom breaks. Handouts were given to all, along with Georgia Perez’s The Eagle Books provided by Bobby Saunkeah, director of the Chickasaw Nation Diabetic Clinic.

Punta Gorda’s community hospital allowed the team’s registered nurses to administer diabetic screenings, take blood pressure readings and calculate each individual’s Body Mass Index. They were met by Dr. Garcia, who had been the chief physician for two years, and they discussed his overwhelming patient load. He greatly appreciated the team’s ability to instruct each patient. He saw teaching diabetes prevention and maintenance as a critical need, but his large patient load restricted the time he had to thoroughly educate each patient.

The ECU nurses were amazed at how many patients were not aware which foods contained carbohydrates. Many stated, “I do not drink pop; I drink fruit juice,” not realizing juice also has carbohydrates. Patients were in disbelief that half of a banana contained only 15 carbohydrates and a serving of rice was one-third of a cup. They previously thought they had to skip meals or starve themselves to maintain their weight as a method to control this horrible disease and were relieved to learn three balanced meals with a snack is much more efficient in maintaining a normal blood sugar level.

The Belizean Health Care System

Belize is a small country about the size of New Hampshire. It is bordered by Mexico on the northwest, Guatemala to the west and south and the Caribbean Sea on its eastern border. English is the official language of Belize, although Spanish is widely spoken as well. Known as British Honduras from the mid-1800s to 1973, Belize was home to the great Maya civilization, which flourished for hundreds of years, developed a very advanced civilization for its time and grew in size to approximately one million people at its height in the first millennium A.D. Descendants of this civilization are now few in number with the majority living in Toledo, the southernmost district.

A typical dwelling in Belize’s Toledo District, the country’s poorest region. Many of the communities in this district are remote rural villages with severely limited access to medical care.

The Belizean health care system serves 300,000 people living within six districts. Belize District is the largest, with a population of 75,000. Toledo is the smallest district, with 28,000, approximately 6,000 of which live in Punta Gorda. This community suffers basic problems like malnutrition and diarrhea, but diabetes has only recently become an issue and the rural areas are not yet very concerned or know much about the disease. The Toledo District is mainly affected by Type II, or adult-onset diabetes. However, once thought to only afflict the older population, diabetes is now occurring more in younger demographics. Its progress is gradual and effects are slow to present. As a result, it may take a back seat to more immediate or emergent health problems.

Of the 53 rural communities in the Toledo District, 80% are remote, some without roads and accessible only by foot, severely limiting education and access to medical care. The population is very diverse, especially in Punta Gorda. The Maya and Garifuna are considered indigenous, with a holistic way of viewing health, valuing the spiritual aspect as well as physical well-being. Mestizo, Creole, Mennonite, East Indian, Chinese and European make up the remainder of the population, with each ethnicity retaining its own traditions. This makes for a cultural melting pot and mixed influences on the community’s diet and health.

The Belizean Minister of Health is located in Belmopan, the capitol city, in the Cayo District. Regional health services control the allocation of resources to Belize, but sometimes become disconnected from the needs of the smaller, southern region of the Toledo District. This health care system is oriented toward primary health care, as conceptualized at the 1978 International Conference on Primary Health Care in Alma-Ata. This approach has proven to be very efficient and cost-effective.

Curative and preventive health care is an essential element of primary health care. Belizean programs with this focus include community outreach, public health, vector control and psychiatric programs, with an emphasis on maternal and child health. The public and rural nurses contribute to this by educating the community about the health problems specific to young children (0–5 years old) and pregnant mothers. These nurses also give immunizations, perform pre- and post-natal care and address malnutrition, tuberculosis and HIV/AIDS.

The vector control programs focus on preventing malaria, dengue and chagas disease. The public health division goes into restaurants, diners and grocery stores to check sanitation and proper food storage practices. Public health is also responsible for the animal rabies campaign. The Guatemalan and Mexican Boards of Health combine resources with Belize to combat its overwhelming poverty and malnutrition.

The author and her team of Eastern Central University nursing program graduates visited schools and a community hospital in Punta Gorda, Belize, to educate local children about diabetes prevention.

Community participation is key in an effective public health program. The director of public health in the Toledo District plans meetings, organizes reports, obtains supplies and coordinates and collaborates training programs designed to involve the community and increase active participation and interaction in its health care. Health care volunteers are encouraged and given a stipend for their efforts equal to $50 (USD) per month. The Toledo District is the country’s poorest region, with a 79% poverty rate per the 1996 census. The estimated average annual income in Belize varies from $1,000–$3,000 (USD), well below the U.S. average.

Many health problems facing Belizeans are related to the lack of an adequate supply of safe water and public sanitation. Illnesses are often transmitted through contaminated food and water. The Toledo District has the lowest levels of available safe water. Thirty percent use streams, rivers and creeks as a water source for bathing and laundry as well as drinking, cooking, washing and preparing food. Bodily wastes can potentially come in contact with water sources, compounding the prevalence of illnesses and disease.

Access to health care is a major problem, especially in remote, rural areas of Belize. Isolated villages suffer from inconsistent care and their most vulnerable populations, young children, endure high incidences of child mortality. A mobile health system, comprised primarily of public health nurses, tries to combat this by going out into these areas and giving immunization shots and other health care. Polyclinics, such as the one visited in Punta Gorda, are outpatient facilities aimed to improve primary care and represent an attempt to spread some of the concentrated health care from the bigger cities to rural areas. Patients requiring additional care and treatment are usually referred to a city hospital, but for most in Punta Gorda, transportation is a problem as well. The sole doctor for Punta Gorda’s polyclinic has days where up to 100 patients need his services. So given the heavy case load and frantic pace, patient health care education and disease prevention can easily go unaddressed.

Overall, there is a shortage of doctors and health care workers in Belize. Only a few medical schools exist and nurses seeking an advanced practice degree must travel outside the country to obtain one. The United States, as well as Nigeria and Cuba, aid in supplying doctors to Belize, but the growing population needs more doctors than are currently practicing. Due to the demand for health care personnel, educational requirements for health care positions are much lower. A large majority of the health care centers are not fully staffed, but even when they are, they still lack a complete range of health care services. Certified nursing assistants are utilized to a much higher degree in Belize compared to the United States and are in high demand. Dieticians are needed because of widespread hypertension, obesity and diabetes. Effective results are dependent on the dieticians’ ability to incorporate the cultural and traditional diet of the different ethnicities living in Belize.

With so many problems facing this health care system, it is a matter of deciding not only which improvements benefit the greatest number of people, but also determining which are realistically achievable. Yet, like the old saying goes, climbing a mountain starts with small steps.

Cultures Coming Together

Not only did diabetes education take place, but also a cultural exchange between the Chickasaw Nation and the Mayan and Garifuna tribes. This was a continuing practicum experience for the graduate nurses of ECU as well.

One of the main tasks given to the team of nurses was to serve as guest lecturers at the Belize Diabetes Association, the Toledo Chapter’s inaugural support group meeting. The seminar was coordinated by Cherry Mae Avilez, District Health Educator, and Rhoda Duncan, president of the local Diabetic Chapter. Also attending was the president of the National Diabetes Association of Belize, Anthony Castillo. The team of five ECU nurses presented an educational program that incorporated the history of diabetes mellitus in Chickasaw Native Americans, the pathophysiology of the disease and prevention techniques like exercise, carbohydrate control and portion size. Also included were blood sugar screenings, group exercises, skits, visual aides of portion sizes and local healthy snack choices. The blood sugar screenings showed several members of the audience having levels well into the 400s. With the help of Melissa Vavricka Conway, a Chickasaw Nation diabetic dietician, the indigenous community was educated on correct portion and proper food selection in relation to the local diet. Attendees enjoyed a “portion-correct” meal of local foods, prepared by “Miss Ruth,” a local diabetes success story. She was diagnosed with diabetes approximately six months before and had since lost 35 pounds through exercise and successfully controling her blood glucose levels.